CLM-2026-004059
Riverside Primary Care Associates, Family Medicine. Service 2026-05-09 at office (POS 11). Received 2026-06-06.
Member
Resolved through the identity graph
- Member
- Teresa Gutierrez
- Member ID
- UHC-30469-27
- Date of birth
- 2001-03-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407895
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2514
- Coverage period
- 2024-05-01 to 2026-07-10
- Deductible
- $410.21 of $1,000.0041%
- Out-of-pocket maximum
- $250.84 of $4,000.006%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6269804525
- Network
- In network
- Rendering NPI
- 3443446513
- Location
- Los Angeles, CA · TIN 64-8796526
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 90471 | Immunization administration | — | 1 | 1 | $41.00 | $25.42 | — | — | PendedIDQ |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $193.00 | $119.66 | — | — | PendedIDQ |
| 3 | 36415 | Venipuncture | — | 1 | 1,2 | $15.00 | $9.30 | — | — | PendedIDQ |
| Totals | $249.00 | $154.38 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-649212
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003904; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-05-09: MEDICARE-ADV-A (MA), effective 2024-05-01, terms 2026-07-10. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Primary Care Associates (6269804525). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Primary Care Associates2026-05-09 16:51
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003904; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004060 | 2026-05-09 | Summit Family Practice | $249.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.